Introduction
Caesarean scar ectopic pregnancy (CSP) is a rare but increasingly common form of ectopic pregnancy where the gestational sac implants within the scar of a previous caesarean section. With the rise in caesarean deliveries, understanding and managing CSP is crucial for obstetricians and gynecologists.
Incidence and Diagnosis
📈 Rising Incidence:The number of CSP cases is climbing due to the increased frequency of caesarean sections.
Estimates of CSP incidence range from 1/1800 to 1/2500
of all pregnancies.
It has been estimated that 6.1% of
pregnancies in women with at least one previous CS and
a diagnosis of ectopic pregnancy will be CSP
🩺 Diagnosis:
Early and accurate diagnosis is vital. A high index of suspicion is necessary, particularly in women with a history of caesarean delivery presenting with atypical bleeding. Ultrasound, especially transvaginal with color Doppler, is the gold standard for diagnosing CSP.
if suspicion we can use MRI
Pathophysiology
🔬 Mechanism: CSP occurs when the blastocyst implants into the scar tissue of a previous caesarean section. Factors contributing to this include endometrial and myometrial disruption.
⚠️ Risk Factors:
CSP can occur even after a single caesarean section, with higher risk noted in those who had caesarean sections for breech presentations.
Clinical Presentation
🤒 Symptoms:Patients may present with minimal symptoms like slight vaginal bleeding and abdominal discomfort. Severe cases may involve acute pain and significant bleeding, indicating possible rupture.
🚨 Complications:
CSP poses risks such as
major hemorrhage and potential hysterectomy, making early diagnosis and management crucial.
Management Options
👉Medical Management
1) Methotrexate:The primary medical treatment involves systemic administration of methotrexate, particularly effective in stable, unruptured cases with low hCG levels (<5000 IU/L) and early gestational age (<8 weeks).
2) Local Embryocides:Agents such as methotrexate, potassium chloride, and etoposide can be injected locally into the gestational sac under ultrasound guidance.
👉Surgical Management
1) Dilatation and Curettage:Suitable for endogenic CSP with adequate myometrial thickness, performed under ultrasound guidance to ensure complete tissue removal.
2) Hysteroscopic Resection: Used to remove the CSP mass, either as primary treatment or following medical management.
3) Laparoscopic/Abdominal Resection:Preferred for exogenic CSP with thin myometrium, offering quicker recovery and early discharge.
👉Combined and Sequential Management
1) Chemo-embolisation and Surgical Resection: This approach combines uterine artery embolisation (UAE) with surgical removal, reducing bleeding risks and enabling quicker recovery.
2) Sequential Management: Involves initial medical management followed by surgical intervention, particularly beneficial for persistent CSP masses.
Follow-Up and Recurrence
🔍 Monitoring: Continuous follow-up is required until the CSP mass completely resolves. This includes monitoring hCG levels and ultrasound assessments.
🔄 Recurrence Risk:
Recurrence of CSP ranges from 3.2% to 5.0%, particularly higher if the myometrial thickness is less than 5 mm. Surgical repair of the uterine defect can help reduce recurrence risk.
Future Pregnancies
🩺 Early Monitoring:
Future pregnancies should be closely monitored with early ultrasounds to rule out CSP recurrence.
🤰 Delivery:
Subsequent deliveries are typically via cesarean section to minimise the risk of uterine rupture and ensure proper closure of the lower uterine segment.
Conclusion
Managing CSP requires a multidisciplinary approach and significant expertise to prevent complications. Preventive strategies should focus on reducing unnecessary caesarean sections. Clinicians must emphasize the long-term risks associated with CSP, such as placenta accreta, when counselling women considering caesarean delivery for non-medical reasons.
reference : Cesarian.scar ectopic.preg tog 2017.
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